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General NPI Number Information
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NPI Number | 1659829562
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Entity Type | Organization
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Legal Business Name | SPINE STOP PORTLAND, PLLC
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Dates
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Enumeration Date | 09/20/2016
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Last Update Date | 09/20/2016
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Provider Practice Location Address
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Address Line | 305 S BROADWAY ST
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City | PORTLAND
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State | TN
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Zip | 37148-1413
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Country | US
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Telephone | 270-237-3304
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Fax | 270-237-3305
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Provider Business Mailing Address
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Address Line | 352 OLD GALLATIN RD
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City | SCOTTSVILLE
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State | KY
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Zip | 42164-8666
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Country | US
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Telephone | 270-237-3304
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Fax | 270-237-3305
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Authorized Official
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Title or Position | MEMBER
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Name | DR. GRANT G WATKINS II
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Credential | D.C.
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Telephone | 270-237-3304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2848
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License Number State | TN
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